Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winnfield Nursing And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
Infection control failures were observed throughout the facility, including heavily soiled resident rooms, unclean shower rooms with urine odor, overflowing trash, soiled linen and briefs left uncontained, and a whirlpool with fecal matter near the drain. A resident on droplet precautions had the sign posted on the wrong door, housekeeping staff lacked training on cleaning chemicals, dwell times, and soiled linen handling, and a RN failed to wear a gown while providing direct care to a resident on EBP.
Improperly Fitting Protective Helmet: A resident with a hx of TBI, SAH, schizoaffective d/o, and severe cognitive impairment was supposed to wear a protective helmet when out of bed, but was repeatedly observed without it. When staff placed the helmet on him, he said it was too big and covered his eyes; the DON confirmed it did not fit properly and had not fitted him for the helmet.
Failure to notify the physician and resident representative occurred when an LPN discovered new dark purple facial bruising of unknown origin on a resident with severe cognitive impairment and multiple psychiatric diagnoses. The resident denied a fall and pain, but the record showed no documentation that the MD or representative were informed, and the DON and admin later confirmed the notifications were not made.
A resident was discharged from Medicare Part A skilled services even though benefit days remained, and the SNF ABN Form CMS-10055 was not given to the resident or RP before the service ended. An MDS staff member confirmed the resident stayed in the facility after skilled services stopped and acknowledged the notice was not sent.
Failure to Protect Resident PHI and Medical Record Confidentiality: Empty medication blister packs with resident names and medication labels were found outside the dumpster area, and an unattended med cart was observed with an EMR screen open and a resident's PHI visible. S10 Dietary and the DON confirmed the labeled packs should not have been outside the dumpster area, and an LPN confirmed the PHI on the cart screen was visible while she was away.
Soiled Privacy Curtain in Resident Room: A resident’s privacy curtain was repeatedly observed with multiple black and brownish-orange stains, and the administrator confirmed the condition. Staff interviews revealed the facility did not have a general housekeeping policy or a policy for cleaning privacy curtains, while housekeeping said visibly soiled curtains were removed and replaced. An LPN later confirmed the curtain was still visibly soiled and should not have been.
Failure to Provide Needed ADL Hygiene Care: Two residents did not receive required personal hygiene assistance. One resident with severe cognitive impairment was observed with long facial hair and dirty, jagged fingernails, and staff confirmed the resident had not been shaved or given nail care. Another resident with severe cognitive impairment and no refusal of care was scheduled for baths 3 times per week but received only 7 baths in 30 days; the RP reported the resident had not been bathed on schedule and was found wet and in soiled clothing.
Failure to maintain nutrition and tube feeding orders: One resident with dementia and psychiatric diagnoses had ongoing weight loss after an RD recommended weekly weights, but the facility did not implement the recommendation. Another resident with a PEG tube and an order for Glucerna at 50 mL/hr missed portions of tube feeding during dialysis and other periods when the pump was idle or disconnected, and staff confirmed the resident did not receive the ordered amount.
A resident with COPD, SOB, HF, and other diagnoses was ordered O2 at 2 L/NC PRN for SOB, but was observed receiving O2 at 4 L/NC. The oxygen tubing and humidifier bottle were repeatedly found unlabeled, and an LPN stated she did not know the prescribed flow rate and confirmed the resident’s O2 had not been administered as ordered.
Expired medications were found available for use in unlocked E-kits and an OTC stock cabinet. An LPN observed broken locks on multiple emergency medication kits, and those kits contained expired IV fluids, injectables, and oral meds. The OTC cabinet also contained several expired products, including antacids, iron, magnesium, and meclizine.
Failure to promptly obtain and report ordered lab results. A resident with weakness, dysphagia, and prior CVA had cough, malaise, and body/joint pain, and an NP ordered a chest x-ray, flu swab, CBC, and BMP after noting no recent imaging or labs. The record showed no documentation that the results were obtained, an LPN later learned the resident was Flu A positive, and the DON confirmed the facility did not follow up to ensure the orders were completed or that the results were received.
Improper food storage and labeling were observed in the kitchen. Surveyors found opened and undated items in the walk-in refrigerator, including green onions, shredded lettuce, and an opened yogurt container, and found hamburger patties and chicken tenders in the freezer open to air, not sealed, and undated, along with food items on the freezer floor. A clear plastic container of cereal on the prep counter was mislabeled as ground meat and had no open date. Dietary staff and the ADM confirmed the items were improperly stored and labeled.
Improper Disposal and Storage of Garbage and Refuse: Survey observation found the facility’s dumpster area unkempt, with a moderate amount of empty boxes and litter outside the dumpster area and the dumpster door open. An S10Dietary and the ADM both confirmed the area was not maintained as required by facility policy, which stated dumpsters should be kept clean and sanitary, covered, and free of litter.
A resident with severe cognitive impairment and multiple diagnoses was not assisted to the dining room for meals as required by their care plan, despite being dependent on staff for eating and mobility. Staff interviews and observations confirmed that the resident remained in their room during meals, contrary to documented fall prevention measures.
The facility did not ensure that two residents' discharges were properly documented or that written instructions and discharge planning were provided, including the basis for discharge, medication reconciliation, and referrals for caregiver support. Staff interviews confirmed that required discharge documentation and procedures were not completed.
Two residents were discharged without complete discharge summaries, missing required information such as a recapitulation of their stay, final status at discharge, and medication reconciliation. Documentation was either incomplete or missing key details, and staff confirmed that the necessary discharge information was not provided or properly recorded.
A resident with a history of substance use and multiple behavioral health diagnoses was not care-planned for substance abuse, and ongoing concerns about drug diversion and active substance use were not addressed by staff. Provider notes documented the resident's diversion and abuse of medications, but these issues were not acted upon, and required monthly urine drug screens were not performed as ordered.
A resident's admission and Quarterly MDS assessments failed to accurately reflect their diagnoses of PTSD, history of suicidal behaviors, suicidal ideations, and substance use/abuse, despite these being documented in the medical record and social services assessments. Staff interviews confirmed the omissions and acknowledged that these conditions should have been included in the MDS.
A resident with multiple behavioral health diagnoses was admitted without a baseline care plan being developed within 48 hours, as required by facility policy. The DON confirmed that no baseline care plan was created to address the resident's immediate needs after admission.
A resident with multiple behavioral health diagnoses, including substance abuse, suicidal ideations, and PTSD, was not provided with a comprehensive, person-centered care plan addressing these conditions. Staff confirmed that the care plan did not include interventions for these significant issues, contrary to facility policy.
A resident with multiple mental health diagnoses and a history of substance abuse was not referred for mental health services upon admission, despite facility protocols and identified needs. The resident did not receive timely or ongoing mental health evaluations, with gaps in monthly follow-up visits while on antipsychotic and antidepressant medications.
A resident with moderate cognitive impairment was physically abused by another resident during breakfast. The aggressor, also with moderate cognitive impairment, hit the victim in the face after a dispute over milk. The incident was witnessed by CNAs, and the facility's abuse prevention policy failed to prevent this occurrence.
The facility did not meet residents' nutritional needs by failing to serve the correct portion sizes as per the menu. During lunch, six residents on a regular diet received improper portions, with five receiving one small chicken leg and one receiving two small chicken legs, which were not a double portion. The menu specified a 3 oz. portion size for Baked Chicken, but the served portions were inadequate. This was confirmed by the Dietary Manager and Regional Director of Nutritional Services.
The facility failed to adhere to professional food safety standards, as evidenced by moldy bread, expired hot dog buns, and undated cornstarch in the dry storage area, along with an unsealed, undated pad of butter in the refrigerator. These deficiencies were observed with the Dietary Manager and could impact any resident consuming meals from the kitchen.
A resident with legal blindness and cognitive impairments did not have a call light within reach, as required by her care plan. Observations showed the call bell was placed across the room, and staff interviews confirmed the issue was due to the absence of an extension cord. The resident had to yell to communicate her needs.
A resident with mental health disorders was physically abused by another resident with a history of altercations. The incident occurred when one resident tapped the other on the shoulder, leading to a physical altercation. Despite the facility's policy on abuse prevention, the measures in place were insufficient to prevent the incident.
The facility did not thoroughly investigate an incident where a resident tapped another, leading to a physical altercation. Witness statements from staff present during the incident were not obtained, and necessary safety checks on the behavioral unit were not conducted. The administrator confirmed the investigation was incomplete.
A resident with dementia and depression experienced significant weight loss due to the facility's failure to document meal intake and provide one-on-one dining assistance as care planned. Observations showed the resident eating unsafely without supervision, and the DON acknowledged the lack of documentation and assistance.
A resident with multiple diagnoses, including Down's Syndrome and Dementia, was observed with long chin hairs over several days, despite regular bathing and no refusal of care. Staff acknowledged the need for shaving, but the issue persisted, impacting the resident's dignity and quality of life.
The facility failed to implement care plans for two residents, leading to a deficiency in monitoring and recording food intake. One resident, with severe cognitive impairment, experienced a 17% weight loss over three months due to unrecorded meal intake on 36 out of 39 days. Another resident, with dementia and intellectual disabilities, had a 12% weight loss over four months, with meal intake unrecorded on 32 out of 39 days. The DON acknowledged the failure to document as required.
A resident with moderate cognitive impairment and impaired mobility was found with a broken self-release belt buckle on his wheelchair. Despite reporting the issue to a nurse, the broken buckle was observed on multiple occasions, and staff confirmed the failure to address the problem promptly.
Infection Control Program Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent communicable diseases and infections. During observations, multiple resident rooms were found with heavily soiled floors, debris, trash overflow, spilled food and liquids, and soiled adult briefs left on the floor or on a bed. Room B had a heavily soiled floor with debris and trash overfilling the trashcan, Room E had black buildup on the floor with personal items and popcorn spilled on the floor and a soiled brief on the bed, and Room C had milk spilled near the bed with a soiled brief beneath the bed. Hall X and Hall Y shower rooms were also observed with strong urine odors, overflowing trash cans with soiled briefs, puddles of liquid on the floor, soiled linen and personal clothing left uncontained, and a whirlpool with a small amount of feces near the drain area. The facility also failed to ensure droplet precautions signage was posted for a resident who was COVID/flu positive. Staff identified that the resident was on Hall X, but the droplet precaution sign was placed on the door of an empty room instead of the resident’s room. The sign was then moved to the correct door during the observation. In addition, shower rooms did not have cleaning products available for staff to clean between resident uses, and staff stated they had to locate housekeeping to obtain a product. CNA staff reported they did not have access to cleaning products and called housekeeping to clean the shower rooms between uses. Staff interviews and record review showed training gaps related to environmental cleaning and infection control practices. Housekeeping staff stated they had not been trained on the cleaning products used at the facility, did not know the dwell times, and had not been fully trained on handling soiled linen and waste. Several housekeeping staff reported they had not yet been trained on the new Medline cleaning products. For Resident #76, who had diagnoses including ESRD, severe sepsis, recurrent C. difficile enterocolitis, diabetes, dysphagia, heart failure, and hypotension of hemodialysis, the quarterly MDS showed intact cognition and substantial to maximal assistance needs. The resident had orders for multiple wound treatments and Enhanced Barrier Precautions, but during wound care a RN assisted with turning, repositioning, and holding the resident without wearing a gown.
Improperly Fitting Protective Helmet
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not ensured when Resident #25 was not provided a properly fitting protective helmet. Resident #25 was admitted on 01/23/2025 with diagnoses including nontraumatic subarachnoid hemorrhage, generalized anxiety disorder, diffuse traumatic brain injury, schizoaffective disorder, and hypertension. The care plan dated 02/04/2026 identified that he was at risk for injuries/falls and directed that a protective helmet be worn when out of bed, with encouragement due to poor memory. His quarterly MDS with an ARD of 10/13/2025 showed a BIMS of 06, indicating severe cognitive impairment. During observations, Resident #25 was seen sitting in a chair in his room, near the nurse station, and in the dining area without a helmet on, and he stated he did not really wear it anymore. When staff brought the helmet and placed it on him, he stated it was too big and came down over his eyes. The S2 DON observed him with the helmet on and confirmed that it did not fit properly. The S2 DON stated she had implemented the helmet as a fall intervention a few months earlier and had told staff that the resident was to wear it when out of bed, but she did not fit him for the helmet. Later, Resident #25 was observed wearing a different helmet that strapped under the chin, and he stated that it fit nicely and he had no issues wearing it.
Failure to Notify Physician and Resident Representative of New Facial Bruising
Penalty
Summary
Failure to notify the resident, the resident's physician, and the resident representative of a change in status occurred when new facial bruising/discoloration of unknown origin was discovered on Resident #52. Resident #52 was admitted on 12/23/2024 and had diagnoses including schizoaffective disorder, bipolar disorder, recurrent major depressive disorder, unspecified dementia with other behavioral disturbance, and type 2 diabetes mellitus. The resident's annual MDS showed a BIMS score of 6, indicating severe cognitive impairment. The facility incident report documented an injury of unknown origin involving bruising/discoloration to the resident's face, and a progress note recorded dark purple bruising between the eyes with the resident denying a fall and denying pain. The record contained no documentation that the resident's physician or resident representative was notified when the new facial bruising was discovered. During interview, the LPN stated she observed the bruising during the night shift, notified the executive director by telephone, and confirmed she did not notify the physician/nurse practitioner or representative even though she should have. The DON stated she was unsure whether the physician and representative had been notified, and later confirmed the on-call group had received no calls from the facility during the night shift. The administrator also confirmed that the administration, resident representative, and resident physician were not notified of the resident's change in status upon discovery.
Failure to Provide SNF ABN Before Discontinuing Medicare Part A Services
Penalty
Summary
The facility failed to ensure that the SNF ABN Form CMS-10055 was provided to the resident and/or the resident's responsible party before Medicare Part A skilled services were discontinued for Resident #31. Record review showed that Resident #31 was discharged from Medicare Part A services even though benefit days were not exhausted, and the SNF ABN Form CMS-10055 was not provided prior to discharge from skilled services. During interview, the MDS staff member confirmed that Resident #31 remained in the facility after being discharged from skilled services with benefit days remaining and acknowledged that the SNF ABN Form CMS-10055 was not sent to the resident or the responsible party, although it should have been.
Failure to Protect Resident PHI and Medical Record Confidentiality
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential for 3 of 42 sampled residents. On 01/12/2026 at 9:20 a.m., observation of the outside dumpster area with S10 Dietary revealed 3 medication blister packs on the ground with patient labels still fully intact. One blister pack had Resident #23's name and was labeled Divalproex 125 mg capsule, and 2 blister packs had Resident #45's name and were labeled Naltrexone 50 mg tablet and Amlodipine 10 mg tablet. At 9:22 a.m., S10 Dietary confirmed the empty medication blister packs with Resident #23's and Resident #45's patient information were lying outside the dumpster area and should not have been. On 01/12/2026 at 9:24 a.m., S10 Dietary accompanied the surveyor to the S2 DON office with the 3 empty medication blister packs, and S2 DON confirmed the packs with Resident #23's and Resident #45's patient information were outside the dumpster area and should not have been. On 01/13/2026 at 12:32 p.m., observation on Hall W showed Cart A unattended with the EMR screen open and Resident #66's PHI visible. At 12:34 p.m., S3 LPN stated she had been using Cart A to provide medications to residents on Hall W and confirmed the computer screen displaying Resident #66's PHI was visible while she was away from the cart, but should not have been.
Soiled Privacy Curtain in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Resident #76 when the privacy curtain in the resident’s room was observed to be visibly soiled with multiple black and brownish-orange stains. The soiled curtain was observed on 01/12/2026 at 9:51 a.m. and again at 4:01 p.m., and on 01/13/2026 at 10:00 a.m. the observation was confirmed by the administrator. Interviews with staff on 01/13/2026 revealed that the facility did not have a general housekeeping policy and did not have a policy regarding cleaning of privacy curtains. The housekeeping staff stated that privacy curtains were removed if visibly soiled and replaced with a clean curtain, while the administrator stated she was unaware of the facility’s policy regarding soiled privacy curtains. A later observation on 01/13/2026 at 3:34 p.m., accompanied by an LPN, again confirmed the privacy curtain was visibly soiled and should not have been.
Failure to Provide Needed ADL Hygiene Care
Penalty
Summary
The facility failed to ensure residents who were unable to perform ADLs received necessary services to maintain good personal hygiene for 2 of 3 residents reviewed. Resident #57 had diagnoses including vascular dementia, major depressive disorder, hypothyroidism, anxiety disorder, depression, cognitive communication deficit, and mild cognitive impairment, and had a BIMS score of 4 indicating severe cognitive impairment. The resident required supervision or touch assistance with personal hygiene and was observed with long facial hair and long, dirty, jagged fingernails on multiple occasions. The resident responded yes when asked if he wanted his face shaved and nails cleaned and cut, and staff confirmed the nails and facial hair were long and should have been cut; staff also stated there were no razors available in the building to shave anyone. Resident #58 had diagnoses including generalized muscle weakness, personal history of pulmonary embolism, unspecified sequelae of cerebral infarction, and dysphagia, and had a BIMS score of 6 indicating severe cognitive impairment. The resident required substantial to maximal assistance with personal hygiene, toileting, and bathing and had no behaviors or rejection of care. The resident was scheduled for baths on Monday, Wednesday, and Friday, but the record showed only 7 baths in the prior 30 days when at least 12 were expected. The resident’s responsible party reported concerns that staff were not bathing the resident on scheduled days and that the resident had remained in the same clothes for a week; at the time of interview, the resident was wet, had soiled clothing, and stated she had been calling since early morning for help getting cleaned up.
Failure to Maintain Nutrition and Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that Resident #9 maintained acceptable nutritional status by not implementing the registered dietitian’s recommendation after the resident triggered for monthly weight review due to weight loss. Resident #9 was admitted with diagnoses including schizoaffective disorder, unspecified dementia, bipolar disorder, paranoid schizophrenia, and anxiety disorder, and required set-up assistance with eating. The care plan directed the facility to maintain adequate nutrition and hydration, monitor weights, and document and report significant weight changes. The dietitian noted on 12/11/2025 that the resident should be added to weekly weights and monitored closely, but the weight record showed a decline from 145.8 pounds on 11/01/2025 to 140.8 pounds on 12/01/2025, 138.8 pounds on 01/01/2026, and 136.8 pounds on 01/08/2026. The facility also failed to provide tube feeding as ordered for Resident #76. The resident had an order for Glucerna at 50 mL/hr via pump through a PEG tube. Survey observations showed the tube feeding infusing at 50 mL/hr on 01/12/2026, but the resident left the facility for dialysis and did not receive tube feeding while out; staff confirmed the resident received only 53 mL from 9:51 a.m. to 4:26 p.m. On 01/13/2026, the tube feeding was observed infusing at 50 mL/hr, but the pump was later found alarming and idle, and staff confirmed the resident had received 139 mL from 8:04 a.m. to 1:00 p.m. when 247 mL should have been received. On 01/14/2026, the tube feeding was again observed infusing at 50 mL/hr, and the registered dietitian stated the tube feeding should have been provided as ordered to meet the resident’s nutritional requirements, but was not.
Oxygen Not Given at Ordered Flow Rate and Equipment Unlabeled
Penalty
Summary
Respiratory care was not provided consistent with the resident’s physician order for Resident #76, who was admitted with diagnoses including COPD, shortness of breath, diabetes, dysphagia, heart failure, acute embolism and thrombosis, and hypotension of hemodialysis. The resident’s order directed oxygen at 2 L/NC to keep oxygen saturation greater than 92% as needed for shortness of breath. The resident’s quarterly MDS showed a BIMS score of 15, indicating intact cognition, and the resident required substantial to maximal assistance with toileting, bathing, dressing, personal hygiene, turning, position changes, and transfers. During observations on 01/12/2026, Resident #76 was found receiving oxygen at 4 L/NC instead of the ordered 2 L/NC. The oxygen tubing and humidifier bottle were observed to be unlabeled on multiple occasions, including at 9:51 a.m., 4:01 p.m., and again at 4:26 p.m. when accompanied by an LPN. The LPN stated she did not know the prescribed flow rate for the resident’s oxygen and confirmed the tubing and humidifier bottle were not labeled with the date they were opened, although they should have been. On 01/13/2026, the LPN confirmed the resident’s oxygen had not been administered at the prescribed flow rate.
Expired medications found in unlocked emergency kits and OTC stock cabinet
Penalty
Summary
The facility failed to ensure medications were stored properly in accordance with currently accepted professional principles by allowing expired medications to remain available for use and administration to residents. An undated facility policy titled Medication Storage stated that drugs, treatments, and biologicals must be stored securely and that outdated, contaminated, recalled, deteriorated, unlabeled medications, or those with soiled or broken/cracked containers must be removed from stock and disposed of properly on a continuing basis. During observation of the Room A medication storage room with an LPN, surveyors found three E-kits that were unlocked and contained expired medications. E-Kit #5 had a broken lock and had not been replaced; it contained expired 1/2 Normal Saline bags, Swab Caps, and Biopatches. E-Kit #14 also had a broken lock and contained expired Promethazine, Kayexalate, Flomax, Desyrel, and Toradol. E-Kit #17 had a broken lock and contained expired Norvasc, Nitrostat, Cleocin, Catapres, Plavix, Depakote DR, Lasix, Vistaril, Namenda, Flagyl, and Toprol. Observation of the OTC stock cabinet in Room A also revealed multiple expired medications, including Slo Mg Chloride, Omeprazole, Magnesium, Mucus Relief, Ferrous gluconate, and Meclizine. The LPN confirmed these findings during interview.
Failure to Promptly Obtain and Report Ordered Lab Results
Penalty
Summary
The facility failed to promptly obtain and notify the NP of ordered lab results for Resident #58. Resident #58 was admitted with diagnoses including generalized muscle weakness, personal history of pulmonary embolism, unspecified sequelae of cerebral infarction, and dysphagia, and the admission MDS showed a BIMS of 06 with substantial to maximal assistance needed for personal hygiene, toileting, and bathing. On 01/07/2026, the NP documented that the resident continued to feel unwell with lethargy, malaise, body/joint pain, and cough, and ordered a chest x-ray, flu swab, CBC, and BMP after noting there had been no imaging or labs ordered since the symptoms began. The record review found no documentation that the results of the 01/07/2026 orders were obtained. Departmental progress notes showed that on 01/11/2026 an LPN was notified that Resident #58 was positive for Influenza A, and the NP was made aware with new orders for isolation precautions. During interview, the LPN stated she did not know whether the facility had the lab results from the 01/07/2026 orders and did not know why there was a delay. The DON confirmed the facility did not follow up to ensure the orders were completed and had not received a copy of the lab results until they were requested on 01/14/2026.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Food items were not stored in accordance with professional standards for food service safety in the kitchen. During observation of the walk-in refrigerator, surveyors found 1 bag of green onions opened and undated, 1 bag of shredded lettuce opened and undated, and 1 Activia yogurt that was opened with yogurt present on the packaging. The dietary staff member confirmed that the green onions and shredded lettuce should have been sealed and labeled with an open date, and that the opened yogurt should not have been present in the refrigerator and should have been discarded. In the walk-in freezer, surveyors observed 1 box of hamburger patties and 1 box of chicken tenders open to air, not sealed, and undated. They also found 2 chicken tenders and 1 cup of ice cream on the freezer floor. The dietary staff member confirmed the hamburger patties and chicken tenders should have been stored in sealed containers with open dates, and that the items on the freezer floor should not have been there. In addition, a clear plastic container of cereal was observed on the kitchen prep countertop labeled as ground meat and without an open date; the dietary staff member confirmed it was mislabeled and missing an open date. The findings were later discussed with the administrator and regional dietitian, who confirmed the food items in the freezer, refrigerator, and dry storage were improperly stored and labeled.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
Garbage and refuse were not properly disposed of in the facility’s outdoor dumpster area. Review of the facility’s undated policy stated that garbage and rubbish would be disposed of to ensure a clean and sanitary kitchen and to avoid encouraging insects or rodents, and that outside dumpsters would be maintained in a clean and sanitary condition with outdoor trash receptacles kept covered and the surrounding area free of litter. On 01/12/2026 at 9:16 a.m., survey observation found a moderate amount of empty boxes and litter outside the dumpster area, and the dumpster door was open. During an interview at that time, S10Dietary confirmed the dumpster area was unkempt, with empty boxes and litter surrounding it, and stated this should not have been. S10Dietary also confirmed the dumpster door should have been closed. Later that day, S1ADM also confirmed the dumpster area was unkempt with empty boxes and litter around it, and that the dumpster door was open and should not have been.
Failure to Implement Person-Centered Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one resident with multiple complex diagnoses, including schizoaffective disorder, bipolar type, type 2 diabetes, hypertensive heart disease, anxiety, a history of falling, and dementia with agitation. The resident was assessed as having severe cognitive impairment and was dependent on staff for eating, mobility, transfers, and personal hygiene. The care plan specifically instructed that the resident should be assisted to the dining room for all meals as part of fall prevention measures. Despite these documented care plan instructions, observations and staff interviews confirmed that the resident was not assisted to the dining room for breakfast or lunch on the day in question. The resident was found in her room with a lunch tray, having only consumed milk and leaving the rest of the food untouched. Multiple staff members, including CNAs and an LPN, acknowledged that the resident should have been assisted to the dining room for meals but was not, in direct contradiction to the care plan.
Failure to Document and Prepare Safe Resident Discharges
Penalty
Summary
The facility failed to ensure proper documentation and preparation for the discharge of two residents, as required by its own policies and regulatory standards. For both residents, there was no documentation in the medical record specifying the basis for their discharge, nor evidence that written discharge instructions were provided to or discussed with the residents or their responsible parties. Additionally, there was no documentation of discharge planning that addressed caregiver support or referrals to local contact agencies, despite the facility's policy requiring such actions. One resident, admitted with multiple complex diagnoses including a right tibia fracture, MRSA infection, diabetes, and a history of venous thrombosis, was noted to have intact cognition and expressed a desire to return home. The resident's insurance coverage ended, and although the resident was informed of the option to pay out of pocket, this discussion and the resident's refusal were not documented. The discharge form was only partially completed, and there was no record of medication reconciliation, discharge instructions, or coordination of care in the resident's file. The second resident, admitted for short-term therapy following a stroke and with diagnoses including Alzheimer's disease and hemiplegia, also had no documentation in the medical record regarding the reason for discharge or any instructions about medications provided at discharge. Progress notes indicated the resident was discharged home with medications and that a follow-up evaluation was planned, but there was no evidence of written instructions or comprehensive discharge planning. Interviews with facility staff confirmed that required documentation and discharge procedures were not completed for either resident.
Incomplete Discharge Summaries and Missing Required Documentation
Penalty
Summary
The facility failed to provide complete and compliant discharge summaries for two of three residents reviewed for discharge. For both residents, the discharge summaries were missing essential elements required by facility policy and federal regulations, including a recapitulation of the residents' stay with diagnoses, course of illness or treatment, pertinent lab, radiology, and consultation results, a final summary of the residents' status at the time of discharge, and a reconciliation of all pre-discharge medications with post-discharge medications. For one resident, the medical record review showed an incomplete discharge summary document, lacking the required information and only partially filled out. The document was provided to the resident at discharge, but it did not include a comprehensive summary of the resident's stay, status at discharge, or medication reconciliation. Interviews with facility staff confirmed that the discharge summary was not completed as required and that the responsibility for discharge documentation was not clearly followed. For the second resident, the discharge documentation included a progress note and a discharge summary form, but these also lacked critical information. There was no documentation of the reason for discharge, no list of medications provided at discharge, and no record of instructions given to the resident. The discharge summary form was not signed by the resident and did not include a summary of the resident's diagnoses, treatment course, or status at discharge. Staff interviews confirmed these omissions and acknowledged that the required documentation was not present in the resident's medical record.
Failure to Provide Behavioral Health Services and Monitor Substance Use
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a documented history of substance use and multiple behavioral health diagnoses, including adverse effects of methamphetamines, cannabis abuse, suicidal ideations, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. The resident's comprehensive care plan did not address their history of substance use/abuse, despite this being known at admission and confirmed by both the administrator and MDS coordinator. Additionally, the resident's Minimum Data Set (MDS) assessments did not indicate substance use/abuse or PTSD, contrary to the resident's medical history. Provider progress notes documented ongoing concerns, including drug diversion, active substance abuse within the facility, and the resident taking medications not prescribed to them. These concerns were not addressed by facility staff, and the administrator was unaware of these issues at the time of the resident's death. Furthermore, although there was a physician's order for monthly urine drug screens (UDS), these were not performed as ordered after the initial positive result for methamphetamine. Staff interviews confirmed that the required monthly UDS were not completed.
Inaccurate MDS Assessments for Resident with Psychiatric and Substance Use History
Penalty
Summary
The facility failed to ensure that both the admission and Quarterly Minimum Data Set (MDS) assessments accurately reflected a resident's clinical status. Specifically, the MDS assessments did not include the resident's diagnoses of PTSD, history of suicidal behaviors, suicidal ideations, or substance use/abuse, despite these being documented in the resident's medical record and social services assessments. The resident's admission and Quarterly MDS both recorded a BIMS score indicating intact cognition and omitted critical psychiatric and substance use diagnoses. Interviews with facility staff confirmed that the resident's social services history and initial assessment identified PTSD, increased anxiety, and a history of substance use/abuse, but these were not reflected in the MDS assessments. The omission was acknowledged by both the Social Services Director and the Administrator, who confirmed that the relevant diagnoses and history should have been included in the MDS documentation.
Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. According to the facility's policy, a baseline care plan is required to be created promptly upon admission to address the resident's immediate needs until a comprehensive care plan is completed. Record review showed that the resident, admitted with multiple complex diagnoses including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder, did not have a baseline care plan in place. During an interview, the Director of Nursing confirmed that a baseline care plan was not developed for this resident, despite policy requirements.
Failure to Develop Comprehensive Care Plan for Resident with Complex Behavioral Health Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident, as required by its own policy. The resident was admitted with multiple diagnoses, including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, a history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. Review of the resident's medical record and care plan revealed that the care plan did not address suicidal ideations, history of suicidal behavior, PTSD, or substance use/abuse. Facility staff interviews confirmed that these issues were not included in the care plan, despite the expectation that they should have been.
Failure to Provide Timely and Ongoing Mental Health Services
Penalty
Summary
The facility failed to provide mental health services in accordance with professional standards for a resident admitted with multiple mental health diagnoses, including PTSD, generalized anxiety disorder, bipolar disorder, major depressive disorder, and a history of substance abuse and suicidal behavior. Upon admission, the resident's social services assessment identified significant mental health needs, but a timely referral for mental health services was not made. Although facility protocol required automatic referral for residents with mental health diagnoses, this was not followed, and the resident was not referred for mental health services until several weeks after admission. Additionally, the facility did not ensure that mental health services were provided on a continual basis. After the initial psychiatric evaluation and two follow-up visits, there were no further mental health encounters documented for the resident, despite ongoing use of antipsychotic and antidepressant medications. Staff interviews confirmed that the resident should have been seen monthly by the mental health nurse practitioner, but this did not occur after the last documented visit.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #3, who has a history of schizoaffective disorder, bipolar type, anxiety disorder, major depressive disorder, depression, glaucoma, legal blindness, and cognitive communication deficit, was involved in an incident with Resident #5. Resident #3 has a BIMS score indicating moderate cognitive impairment. During breakfast, Resident #3 accused Resident #5 of taking her milk, which led to Resident #5 physically hitting Resident #3 in the face. This incident was witnessed by two CNAs who were present in the dining room. Resident #5, who also has a history of schizoaffective disorder, depressive type, anxiety disorder, diffuse traumatic brain injury, and cognitive social or emotional deficit following cerebrovascular disease, was identified as the aggressor in this incident. Resident #5 has a BIMS score indicating moderate cognitive impairment. The facility's incident report and witness statements confirm that Resident #5 made contact with Resident #3's face with her fist, resulting in discoloration to Resident #3's upper lip. The facility's policy on abuse prevention was not effectively implemented to prevent this incident of resident-to-resident abuse.
Failure to Meet Nutritional Needs Due to Improper Portion Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to the established portion sizes as outlined in the menu. During an observation of lunch preparation, it was noted that six residents on a regular diet were served improper portion sizes. Specifically, five residents received only one small chicken leg, and one resident received two small chicken legs, which were incorrectly considered a double portion. According to the facility's Production Sheet Main Menu, the portion size for Baked Chicken was specified as 3 oz. An interview with the Dietary Manager and the Regional Director of Nutritional Services confirmed that one chicken leg without the bone was approximately 2 oz., and residents should have been served two chicken legs to meet the 3 oz. portion size requirement.
Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety. During an observation of the kitchen's dry food storage area, a loaf of bread with mold was found, along with two packages of hot dog buns that had expired. Additionally, an opened and undated box of cornstarch was discovered. In the walk-in refrigerator, a used pad of butter was found unsealed and undated. These deficiencies were identified during an observation with the Dietary Manager and had the potential to affect any resident consuming meals from the facility's kitchen.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, identified as Resident #30, by not ensuring the availability of a call light within reach. Resident #30, who was admitted with diagnoses including legal blindness, major depressive disorder, schizoaffective disorder, and cognitive communication deficit, had a care plan that specified the need for a call light to be within reach due to her sensory and perception alterations. Despite this, observations revealed that the call bell was placed on a nightstand across the room, out of reach, and not accessible to the resident. Interviews with the resident and staff confirmed the deficiency. The resident expressed difficulty in locating the call bell at night due to her blindness. A CNA explained that the call bell was not in use because its cord would obstruct the walkway if positioned near the resident's bed. The RN confirmed the call bell's inaccessibility, attributing it to the absence of an extension cord, which the facility was awaiting. This situation left the resident to resort to yelling to communicate her needs.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #76, who has a history of mental health disorders including Bipolar Disorder, Schizophrenia, and Dementia, was physically abused by Resident #68. The incident occurred when Resident #76 tapped Resident #68 on the shoulder, causing Resident #68 to become frightened and grab Resident #76's hair. This resulted in Resident #76 falling to the ground. The facility's policy on abuse prevention, which includes protection from resident-to-resident abuse, was not effectively implemented in this case. Resident #68, who has a history of altercations and is diagnosed with Paranoid Schizophrenia and other mental health conditions, was involved in the altercation. The incident was reported by a CNA who witnessed the event and intervened to separate the residents. Despite the facility's awareness of Resident #68's history of altercations, the measures in place were insufficient to prevent the incident. The facility's failure to ensure adequate supervision and intervention led to the physical abuse of Resident #76.
Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation of an incident involving resident-to-resident abuse. On August 11, 2024, a Certified Nursing Assistant (CNA) reported that while distributing snacks in the special care unit's common area, one resident tapped another on the shoulder, causing the second resident to become frightened and grab the first resident's hair. During the altercation, the first resident fell to the ground. The residents were immediately separated, and the second resident was placed on one-to-one supervision before being sent to a behavioral hospital the following day. The facility's investigation into the incident was incomplete. Witness statements were not obtained from the CNA, a Licensed Practical Nurse (LPN), or the Registered Nurse (RN) on duty at the time of the incident. The facility also failed to conduct body audits and safety rounds on all residents in the behavioral unit. The administrator confirmed that the investigation was not completed and acknowledged the failure to obtain necessary witness statements from staff who observed the incident.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure a resident maintained acceptable nutritional status by not implementing appropriate interventions for weight loss. Specifically, the facility did not document the meal intake for a resident as care planned and failed to provide one-on-one assistance during meals. The resident, who had diagnoses including Major Depressive Disorder, Unspecified Dementia, Cellulitis, and Hypertension, experienced a significant weight loss of 17.15% over six months. The resident's care plan included interventions such as one-on-one dining assistance, monitoring food intake, and reporting any decline to the physician and dietician. Observations revealed that the resident was left unattended during meals, leading to unsafe eating behaviors, such as attempting to eat plastic wrap. The staff failed to document the resident's meal intake consistently, with numerous instances of missing documentation over several days. The Director of Nursing acknowledged these failures, confirming that the resident was care planned for one-on-one assistance with dining, which was not provided.
Failure to Maintain Resident's Personal Hygiene and Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not maintaining her personal hygiene, specifically by allowing her to have long, curly chin hairs. The resident, who has multiple diagnoses including Down's Syndrome, Major Depressive Disorder, and Dementia, was observed on multiple occasions with facial hair that was approximately an inch long, covering her entire chin. Despite being bathed regularly and not refusing personal care, the resident's facial hair was not addressed by the staff. Interviews with the facility's staff, including CNAs and the DON, confirmed that the resident had been observed with long chin hairs over several days. The staff acknowledged the need for the resident to be shaved, yet the issue persisted over multiple observations. The resident's care plan indicated she required assistance with personal hygiene, but this aspect of her care was neglected, impacting her dignity and quality of life.
Failure to Monitor and Record Food Intake
Penalty
Summary
The facility failed to implement the care plans for two residents, resulting in a deficiency related to monitoring and recording food intake. Resident #1, who has severe cognitive impairment and a history of weight loss, was not monitored for food intake as required by their care plan. The care plan included interventions such as dietician evaluation, determining food preferences, and monitoring food intake at each meal. However, the Meal Report revealed that food intake was not recorded on 36 out of 39 days, leading to a significant weight loss of 17% over three months. Similarly, Resident #2, who has multiple diagnoses including dementia and moderate intellectual disabilities, also experienced a failure in care plan implementation. The resident's care plan required monitoring and recording food intake at each meal, but the Meal Report showed that this was not done on 32 out of 39 days. This lack of documentation coincided with a significant weight loss of 12% over four months. The Director of Nursing acknowledged the failure to document meal intake for both residents as instructed in their care plans.
Failure to Maintain Safe Patient Care Equipment
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition for Resident #3. Resident #3, who has a history of hypertension, cerebrovascular disease, type 2 diabetes mellitus, and insomnia, was observed with a broken self-release belt buckle on his wheelchair. The resident, who has moderate cognitive impairment and impaired mobility, reported the broken buckle to a nurse but could not recall which nurse. Despite this report, the broken buckle was observed on multiple occasions over several days, indicating a failure to address the issue promptly. On two separate observations, the broken buckle was noted, and interviews with the resident and staff confirmed the issue. The LPN acknowledged that the buckle should not have been broken and that nursing staff are responsible for routinely monitoring the self-release belt. The facility administrator also confirmed the broken buckle, highlighting a lapse in maintaining essential equipment in safe working condition for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winnfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Leaves Nursing & Rehab Center, Llc | 2.3 mi | ★★★★★ | 7 | 0 |
| Wyatt Manor Nursing And Rehab Ctr, Inc | 15.7 mi | ★★★★★ | 10 | 1 |
| Forest Haven Nursing & Rehab Ctr, Llc | 20.8 mi | ★★★★★ | 0 | 0 |
| Natchitoches Community Care Center | 27.7 mi | ★★★★★ | 0 | 0 |
| Colfax Nursing And Rehab, Llc | 28.4 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.